Transforming Communities

Lessons Learned from More Than 30 Years of Healthy Communities Efforts

Joey Vrazel

• Publisher: Leverage Points Press
• Year: 2022
• Edition: 1
• eBook ISBN:
  9798985209211
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

CHAPTER ONE

Laying the Foundation

Setting out to build on the knowledge base of Healthy Communities efforts requires first establishing the key definitions, concepts, and theories that undergird this work and that will form the foundation of an updated framework. Establishment of this foundation is intended to create a shared understanding of the concept of Healthy Communities as well as to identify what makes a community healthy, how this work is different from other community-based efforts, and why these types of efforts are needed. Leading with this information will also help to build a common language that can be used and understood by community practitioners from a wide range of sectors.

At the core of this work is the concept of community. To establish a broad working definition of community and the phrase community-based requires consideration of both people and place. As it relates to people, community includes the total population of members who reside in a specific locality, share government, and often have a common cultural and historical heritage. Community as place includes a geographic setting with natural and physical boundaries, such as a city or a county and its corresponding political jurisdictions (US Environmental Protection Agency, 2002).

Well beyond these descriptions, the people and places that make up a community reflect enormous diversity that cannot be captured simply by population or geographic statistics. Because of this diversity, no two communities are the same even if they are the same size or have similar demographic characteristics. Seeking out and fully understanding the diversity and context are fundamental in Healthy Communities work. Embracing this diversity, with an equity lens, is a core principle that will be discussed in more detail at a later point.

Because communities are dynamic and constantly evolving, the people and places that make up a community continually change. The continual evolution and uniqueness are key factors in Healthy Communities efforts.

Community Health or Healthy Community? What’s in a Name?

Even though organized Healthy Communities efforts have been in progress for over a quarter century, the concept is still relatively new for most people and communities. Although seemingly intuitive and clear, the phrase and associated work of Healthy Communities are often misunderstood in the general public (Hancock & Duhl, 1986; Twiss et al., 2013; Wolff, 2003). Several contributing factors lead to this confusion in our society. Most notably, the words “health” and “healthy” are inextricably linked with health care in the US (Aronson, Norton, & Kegler, 2007). Consequently, even in today’s more modern health environment, being healthy is largely viewed as simply not needing to seek health care (Lavizzo-Mourey, 2014). Another contributing factor is that a community’s health is often described by disease statistics or negative health behaviors. For example, in the County Health Rankings, health outcomes are reflected by measures of premature death and poor physical health days. Similarly, health factors are described by poor health behaviors (e.g., smoking or physical inactivity) or negative health factors (e.g., obesity or sexually transmitted infections) (UWPHI, 2014). For clarity, it would be more accurate to describe these measures as health risk factors.

Health ≠ Healthcare

—DR. DAVID ERICKSON, DIRECTOR OF COMMUNITY DEVELOPMENT, FEDERAL RESERVE BANK OF SAN FRANCISCO

With an increased emphasis in the past decade on the health care system, health insurance, and access to care, combined with a focus on describing a community’s health by disease rates and health risk behaviors, it is understandable why Americans are fixated on this view of “health.” It is also understandable that the phrase and work of Healthy Communities gets confused with health care.

Clarifying and Expanding Our Understanding of Health

Remarkably, as far back as 1948, the World Health Organization (WHO) attempted to address the misperceptions of health by defining health as “a state of complete physical, mental, and social well-being and not merely the absence of disease” (p. 119). In the last half of the twentieth century, there was a concerted effort to shift the focus to health promotion, which was defined as the process of enabling people to increase control over and improve their health, with health being defined as “a resource for everyday life” (World Health Organization, 1986, para. 1; 2009, p. 29). The WHO further expanded on this concept by stating that health is a basic right and is essential for social and economic development (World Health Organization, 2009, p. 17). As our understanding of health has broadened, it has opened opportunities—and clarified the need—for other avenues outside of the health care system and even public health to address the health of communities (Hancock & Minkler, 2012).

On a parallel path, late in the twentieth century, a major paradigm shift occurred in public health that was driven by a large and growing body of evidence revealing that health is largely determined by conditions in the environments (i.e., social, economic, and physical) and settings (e.g., neighborhoods, schools, worksites, and churches) in which people are born, live, learn, work, play, worship, and age (Healthy People 2020, 2010; Irwin & Scali, 2005; McGinnis, Williams-Russo, & Knickman, 2002; Office of Disease Prevention and Health Promotion, n.d.). The conditions and environments that influence health and health behaviors are often referred to as place (Office of Disease Prevention and Health Promotion, n.d.). To further describe this understanding in lay terms, we have learned that “where you live, determines how you live” (Bell & Rubin, 2007, p. 6), and “the choices we make are driven by the choices we have” (Trailnet, 2009, p. 12).

One number may determine how healthy you are and how long you live. It isn’t your weight, cholesterol count, or any of those numbers that doctors look at. It’s your address.

—POLICYLINK

In addition to the material attributes of place, we learned that patterns of social engagement and senses of security and well-being are also affected by where people live. These patterns and conditions (e.g., education, income, social support, housing, and transit) affect a wide range of health, functioning, and quality-of-life outcomes and are largely referred to as the social determinants of health or, more broadly, determinants of health (Healthy People 2020, 2010; Irwin & Scali, 2005). (Determinants can be understood as those factors that have been shown to influence health behaviors and outcomes.)

The Model of Population Health from the County Health Rankings outlined in Figure 1.1 provides an overview of the wide range of factors that have been shown to influence the health of people and places (UWPHI, 2014). Strikingly, the model reveals that when combined, factors in the physical, social, and economic environments (circled in the diagram) account for 50% of the influences on health, with an additional 30% contributed by health behaviors that are influenced largely by those external environments. In contrast to what many might believe, health care—both access to and quality of care—accounts for only around 20% of health outcomes.

Figure 1.1 Significant influences on health behaviors and outcomes

Source: University of Wisconsin Public Health Institute, 2014

As our understanding of the determinants of health has grown, it has revealed not only the positive influences on health but also, as importantly, the negative influences and missing supports that cause significant health disparities among communities and population groups. According to the US Department of Health and Human Services (USDHHS), health disparities represent a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion (USDHHS, 2010b, p. 28).

It is unreasonable to think that people are going to change their behavior easily when so many forces in the social, cultural and physical environment conspire against that change.

—INSTITUTE OF MEDICINE (2000, P. 4)

Health disparities in the US are perhaps best described by the Health and Social Justice Committee of the National Association of County and City Health Officials and Social Justice Committee (2008):

Inequalities in health status in the US are large, persistent, and increasing. Research documents that poverty, income and wealth inequality, poor quality of life, racism, sex discrimination, and low socioeconomic conditions are the major risk factors for ill health and health inequalities. Conditions such as polluted environments, inadequate housing, absence of mass transportation, lack of educational and employment opportunities, and unsafe working conditions are implicated in producing inequitable health outcomes. These systematic, avoidable disadvantages are interconnected, cumulative, intergenerational, and associated with lower capacity for full participation in society. … Great social costs arise from these inequities, including threats to economic development, democracy, and the social health of the nation (p. 4).

As a result of this understanding, the national objectives of Healthy People 2020 include goals to not only eliminate disparities but also achieve health equity and improve the health of all groups. Whereas early strategies for eliminating disparities were focused primarily on diseases or illnesses and on health-care services, the growing understanding and recognition that the absence of disease does not automatically equate to good health led to an expanded focus on improving health. In fact, health equity is defined as the “attainment of the highest level of health for all people” (USDHHS Office of Minority Health, 2011, p. 9).

With mounting evidence that health and health behaviors are significantly influenced by a wide variety of forces, many of which are outside the control of individuals, community-based efforts transitioned from focusing solely on clinical care and individual-level behavior-change strategies to focusing on conditions and influences in the larger community environments (i.e., social, economic, and physical environments) where behaviors take place. This method is widely known as the socio-ecological model or an ecological approach (McLeroy, Bibeau, Steckler, & Glanz, 1988; Stokols, 1996). Although several variations of ecological models exist, most feature the influences on behavior as a series of overlapping layers of influence, in which each layer both influences and is influenced by the other layers (i.e., reciprocal causation; McLeroy et al., 1988). A modified version of an ecological model in Figure 1.2 illustrates the individual surrounded by differing layers of environmental influence.

Figure 1.2 Modified ecological model

As reflected in Figure 1.2, the basis of an ecological perspective is that it takes a combination of individual, environmental (social and physical), and policy-level interventions and conditions to achieve and maintain substantial changes in health behaviors and, ultimately, the health of populations and communities (IOM, 2000; Krieger, Strunk, & Norris, 2013; McKinlay & Marceau, 2000; McLeroy et al., 1988; Stokols, 1996). Moving beyond a sole focus on individual-level behavior change and programs, we have learned that changing or developing policy, systems (e.g., structures, processes, and procedures), and environmental strategies at all layers of influence is the most effective and sustainable way to modify and develop environments to make healthy choices, conditions, and supports available, affordable, and easy for all community members (Krieger et al., 2013; Stokols, 1996). This monumental shift in understanding formed the basis of the modern-day Healthy Communities movement.

Systems change is shifting the conditions that are holding a problem in place.

—SOCIAL INNOVATION GENERATION

The impact of multiple layers of influence on behaviors, and correspondingly, the need for policy, systems, and environmental change strategies to accomplish large-scale population level health impact, cannot be overstated. However, these concepts, no matter how well-explained, are often very difficult for many people to understand. Even for those in the field who understand the significance, identifying and implementing these types of strategies represents a complete shift in thinking and way of working.

What Is a Healthy Community? How Will We Kn...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Tables
• List of Figures
• Introduction
• 1 Laying the Foundation
• 2 Learning about and from the Healthy Communities Movement
• 3 Minimum Specifications and Fundamental Shifts for the Next Generation of Progress
• Appendices
• References
• About the Author